Acute Care Visit (Primary Care)

Last updated: Nov 2025

Acute Care Visit (Primary Care) that’s HIPAA-compliant: capture the visit or upload audio, generate a focused single-issue note, then auto-fill your EHR via the Nudge Chrome extension (edit-before-save).

Who this helps

• Family medicine & internal medicine clinicians

• Urgent-care style visits inside primary care

• APPs (NPs/PAs) standardizing rapid documentation
  
  

What you get

• Structured Chief Complaint, HPI, Focused Exam, Relevant History, Assessment, Plan, Return Precautions

• Optional Point-of-Care results (e.g., UA, strep, flu, COVID, glucose)

• Team-wide formatting controls (bullets/paragraphs) + redaction

• Carry-forward of diagnosis and follow-ups to subsequent visits
  
  

How it works with your EHR

1. Capture or upload in Nudge → draft appears.

2. Review and edit sections (focused by complaint).

3. In your EHR, open a new note and launch the Nudge extension.

4. Select patient + note type → confirm mapping (HPI/Subjective, Focused Exam/Objective, Assessment, Plan, optional POC results) → save & sign.
   No IT project required.
   
   

How to write an Acute Care Visit note

• Chief Complaint: 1 line in the patient’s own words.

• Focused HPI: onset, duration, severity, precipitating event, alleviating/aggravating factors, targeted red-flag screen.

• Focused Exam: only systems relevant to the complaint; include vitals and key maneuvers.

• Assessment: likely diagnosis plus top differentials (and rationale).

• Plan & Return Precautions: diagnostics, treatment, self-care, specific “go to ED/return if…” triggers.

• Follow-Up: clear interval and conditions for sooner return.
  
  

Quick examples

• Sore throat (strep rule-out): Centor criteria; tonsillar exudates/nodes; POC strep; abx vs supportive care; return precautions.

• Dysuria (UTI): onset/frequency/urgency/hematuria; UA dip + culture; first-line abx; hydration; follow-up triggers.

• Acute low back pain: mechanism; red-flag screen; neuro exam/Straight-Leg Raise; NSAIDs, heat, gradual activity; strict return precautions.
  
  

Full Sample Note — Acute Care Visit (Primary Care)

Example only; not medical advice.

Patient: Thomas W., 41M
Chief Complaint: Acute low back pain ×1 week

⸻

HPI / SUBJECTIVE:

Thomas is a 41-year-old man presenting with acute low back pain for 1 week. Pain began after lifting a heavy box at work. It is localized to the right lower lumbar area, described as a dull ache with intermittent sharp twinges, worse with bending or prolonged sitting. He denies radiation to the legs, numbness, weakness, bowel or bladder changes, saddle anesthesia, fever, weight loss, or night sweats.

He has been using ibuprofen and heating pads with partial relief. Past history notable for obesity and hypertension.

PMH:

• Obesity (BMI 32)

• Hypertension

PSH:

• Appendectomy at age 15

Meds:

• Lisinopril 10 mg daily

• Ibuprofen OTC as needed

Allergies: NKDA

FH:

• Father: degenerative disc disease

• Mother: hypertension

SH:

• Works in warehouse

• Non-smoker

• Occasional alcohol

ROS:

• General: No fevers, chills, weight loss

• MSK: Low back pain, no other joint complaints

• Neuro: No weakness, numbness, bowel/bladder changes

• Cardiac: No chest pain

• Pulmonary: No cough, SOB

OBJECTIVE:
PHYSICAL EXAM:
Vitals: BP 132/84, HR 78, BMI 32
General: NAD, moves cautiously
Cardiac: RRR, no murmurs
Pulmonary: Clear bilaterally
Abdomen: Soft, NT/ND
Back: Mild paraspinal tenderness, right lumbar; no midline tenderness, step-off, or deformity; normal curvature
ROM: Flexion limited by pain, extension intact
Neuro: Strength 5/5 throughout, reflexes 2+ symmetric, sensation intact; straight-leg raise negative bilaterally

DIAGNOSTICS:

• No red flags identified → imaging not indicated

• No labs ordered

ASSESSMENT & PLAN:

Thomas is a 41-year-old man with acute mechanical low back pain, most consistent with a lumbar strain. His history and exam are reassuring with no red flags to suggest fracture, infection, malignancy, or neurologic compromise.

1. ACUTE LOW BACK PAIN – LUMBAR STRAIN

• Continue NSAIDs with food; may alternate with acetaminophen

• Encourage early mobility, walking, and gentle stretching; avoid prolonged bed rest

• Topical options: lidocaine patches, heat therapy PRN

• Work note provided for light duty, avoid heavy lifting ×2 weeks

• Patient educated on red flag symptoms (weakness, incontinence, fever, weight loss) and instructed to seek care promptly if they occur

2. HYPERTENSION

• On lisinopril 10 mg daily

• BP today 132/84, reasonable control

• Continue current regimen

3. OBESITY

• BMI 32, risk factor for recurrent back pain and HTN

• Counseling provided on weight loss through diet and exercise

• Discussed long-term benefit of weight optimization on joint and back health

FOLLOW UP: Return in 4–6 weeks if symptoms not improved, sooner if new neurologic deficits or systemic red flag features.

DIAGNOSES:
• M54.5 — Low back pain
• S39.012A — Strain of muscle, fascia and tendon of lower back, initial encounter
• I10 — Essential (primary) hypertension
• E66.9 — Obesity, unspecified

Results (2025)

Focused acute-visit note ready in < 60–90 seconds after capture.
Primary-care teams report 4–6 hrs/week saved and fewer copy-paste errors.

FAQs

Can I force red-flag questions per complaint (e.g., back pain, chest pain)?
Yes. Add complaint-specific prompts and mark them required before export.

Does it support point-of-care entries (strep/flu/COVID/UA)?
Yes. Include result, lot/exp (optional), and interpretation; map to your EHR’s POC fields or Objective.

Can I standardize return-precaution language for the group?
Yes. Set organization-wide defaults and apply them to all acute-care notes.